Psychiatric Times.
No. 2
Behavioral and Emotional Problems Among Children of Drug Abusers
By Catherine Stanger, Ph.D. |
February 1, 2003
Parenting Interventions for Substance-Abusing Parents
In screening families for inclusion in this study, we found that a minority (20% to 25%) of adults in substance-abuse treatment lived with and parented children (Stanger et al., 1999). Most parents were willing to complete a standardized rating form about their children, and 40% reported significant problems in their children. Clinicians who treat parenting drug abusers should assume that a significant percentage of their clients' children have behavioral and/or emotional problems and that parents are willing to report those problems on standardized instruments.
Parenting disruptions appear to be common among substance-abusing parents, and because they are highly predictive of children's problems, our current research focus is on parenting interventions for substance-abusing parents. Parent management training is the most effective approach to the treatment of childhood conduct problems (Conduct Problems Prevention Research Group, 1999; Irvine et al., 1999; Jouriles et al., 2001; Martinez and Forgatch, 2001).
In our work with substance-abusing parents, we selected the Incredible Years parenting curriculum (Webster-Stratton, 1998, 1990). This social-learning-based curriculum focuses on teaching parenting skills to promote positive child behaviors and to reduce inappropriate child behaviors among children ages 3 to 10 years old. Topics are presented using videotape examples reviewed in two-hour group sessions. Videotape vignettes for each topic are shown each week, with the tape stopped for discussion after each vignette. Parents role-play skills in the group, taking turns portraying children and parents. We have also used other parent-training programs that have empirical support when working with individual families or families with older children (Dishion and Andrews, 1995; Forehand and Long, 1996; Patterson and Forgatch, 1987).
Our Incredible Years group participants have included opiate-, cocaine-, marijuana- and/or alcohol(Drug information on alcohol)-dependent women and their male partners, most of whom were also substance-dependent. Many participants had received substance abuse treatment in the past or were in concurrent substance abuse or mental health treatment. Most mothers and approximately half the fathers scored in the clinical range on a standardized measure of symptoms of depression, and most children met DSM criteria for one or more disorders.
We do not exclude active substance users from the group. We feel that parents who are actively using might benefit from the parenting intervention, just as active substance abusers who are depressed can benefit from treatment for depression, even if they are not abstinent (Nunes et al., 1998a). We provide substance-abuse treatment referrals to parents who are actively using drugs or alcohol and who are not engaged in treatment elsewhere. We follow up regularly with parents to assist them in setting up and keeping appointments. We feel this practice most closely reflects community practices, in that parents requesting help with their children generally are not screened for substance use and are not denied such services if they have personal problems such as psychopathology. In order to reach the most children at risk, we offer all interested parents help with parenting.
During the first group meeting, we establish ground rules, and parents have included the rule that attending group under the influence of drugs or alcohol is not acceptable. To the best of our knowledge, all parents have followed that rule. However, we suspect that failure to attend group meetings has, at times, been related to substance use. When parents miss a group meeting for any reason, we call them that evening to schedule a make-up session. We discuss the reason for missing group and make referrals or request permission to contact their current treatment provider if we are concerned that they are using drugs or alcohol or having other problems (e.g., depression).
In our pilot work using the Incredible Years curriculum, we provide parents with incentives for attending sessions, completing their assignments to practice skills at home, and monitoring of their children's behavior and their parenting daily. The incentives are vouchers, which can be traded in for goods and services purchased by research staff. For example, parents have used purchased gift certificates for local recreational activities and small toys to be used as rewards for the children in their home behavioral chart program.
Many other researchers have supplemented behavioral treatment programs with similar voucher programs (Bickel et al., 1997; Budney et al., 2000; Higgins et al., 2000). In addition to directly targeting drug abstinence, contingency management procedures have been used to increase participation in assigned, pro-social, non-drug-related activities outside of therapy sessions (Petry and Martin, 2002; Petry et al., 2000). Participation in these activities was, in turn, highly correlated with drug abstinence, suggesting that improving compliance with treatment can improve outcomes. For this reason, we are using an incentive system to target attendance and compliance with parent training. We hypothesize that incentives will improve outcomes for this challenging population.
Acknowledgment
Dr. Stanger's research on children of substance abusers and parent-training interventions is funded by the National Institute on Drug Abuse.
Dr. Stanger is research associate professor of psychiatry and psychology at the University of Vermont.
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